巴基斯坦的脊髓灰質炎 巴基斯坦的脊髓灰質炎2011年7月7日- 巴基斯坦報告稱，在發生沖突、難以進入的聯邦管轄部落地區（FATA）開伯爾特區，從一名16個月齡的幼兒體內分離出野生3型脊灰病毒（WPV3），該名幼兒于2011年6月9日出現麻痹。這是2011年在亞洲發現的唯一一例野生3型脊灰病毒病例。野生3型脊灰病毒在亞洲的傳播處于即將被消除的邊緣階段，上一病例的發現還是6個多月前，發生在2010年11月18日（同樣也來自聯邦管轄的部落地區，開伯爾特區）。 確認出現野生3型脊灰病毒在巴基斯坦部落地區的持續傳播，嚴重影響了全球消滅野生3型脊灰病毒，特別是對于即將消除這一毒株流行的亞洲而言。在巴基斯坦發現野生3型脊灰病毒，意味著這一危險可能會從這一傳播源蔓延到亞洲無野生3型脊灰病毒的其他地區，甚至會到更遠的地方。在全球范圍內，野生3型脊灰病毒的傳播在2011年達到歷史低點，該毒株在其他地方的流行局限在西非部分地區（科特迪瓦、幾內亞、馬里和尼日爾共有17例）、尼日利亞（5例）和乍得（3例）。世界衛生組織（世衛組織）認為，野生3型脊灰病毒出現進一步傳播的風險很高，特別是考慮到巴基斯坦境內以及巴基斯坦與阿富汗之間的大規模人口流動，以及未來幾個月內，可以預料的因小朝和即將到來的麥加朝圣而引發的大規模人口流動（到沙特阿拉伯王國的麥加朝圣）。2011年，巴基斯坦在高風險地區開展的補充免疫活動（SIAs）的質量較低，同時，生活在受沖突影響部落地區的很大比例兒童仍無法獲得免疫接種。在聯邦管轄的部落地區，特別是在開伯爾特區，過去兩年中，補充免疫活動通常都會遺漏近50%的兒童。除了在開伯爾普赫圖赫瓦及聯邦管轄部落地區的不安全區域存在接觸兒童方面的相關挑戰外，補充免疫活動的質量也因為開伯爾可進入區域及該國其他主要傳播區域遇到的重大業務挑戰而持續受到損害，特別是在俾路支省和信德省。除2011年在亞洲確認的唯一一例野生3型脊灰病毒病例外，巴基斯坦仍然受到野生1型脊灰病毒的全國性地域傳播帶來的影響，與2010年同期出現的14例野生1型脊灰病毒病例相比，2011年已確診57例野生1型脊灰病毒病例（截至2011年7月5日）。為緊急處理這一狀況，在總統閣下的支持下，巴基斯坦政府已于今年啟動了國家脊灰緊急行動計劃。應世界衛生大會要求，該國于2010年設立了獨立監督委員會，以獨立監督無脊髓灰質炎世界的進展情況。然而，該委員會于2011年4月發出警報，指出該計劃的執行所花時間太長，2011年6月東地中海技術咨詢小組的結論亦與此相一致。 為迅速加強對這兩種脊灰病毒毒株的免疫力，目前開伯爾特區正在開展雙價口服脊髓灰質炎疫苗短時間間隔追加劑量策略（SIAD）的補充免疫活動，7月4日為第一階段，7月12日為第二階段。預計，在6月中旬開展的最近一次補充免疫活動中，短時間間隔追加劑量策略仍然無法覆蓋開伯爾特區45%（89449）的目標兒童（Bara Tehsil占80%，約73000人）。使用雙價口服脊髓灰質炎疫苗的（包含1型和3型血清型）國家免疫接種日（NIDs）將于7月18-20日在該國開展。但成功的關鍵是要解決完全可進入地區存在的其余業務挑戰并實行特別外展戰略，使社區完全參與進來，以提高安全欠佳地區人口的可及性。為盡量降低野生3型脊灰病毒再次波及阿富汗的風險，同樣使用雙價口服脊髓灰質炎疫苗的次國家級免疫接種日（SNIDs）活動包括與巴基斯坦的搭界地區將于7月10-12日在該國開展。重要的一點是，亞洲和東地中海各國應加強對急性弛緩性麻痹（AFP）的疾病監測，以便能夠迅速發現脊灰病毒輸入情況，并在出現輸入時促進作出快速應對。各國也應當繼續擴大針對所有脊灰病毒毒株的常規免疫覆蓋面，盡量降低病毒輸入造成的后果。按照世衛組織國際旅行和健康所述建議，來往巴基斯坦的旅客應當受到免疫接種的完全保護。去往巴基斯坦的旅客如果在過去服用過3劑或3劑以上的口服脊髓灰質炎疫苗，應在出發前追加服用一劑。任何未接受過免疫接種，而有意前往巴基斯坦旅行的個人均應完成免疫接種的完整療程。從巴基斯坦出發的旅客應在離開巴基斯坦前完成免疫接種的完整療程，出發前至少要服用一劑口服脊髓灰質炎疫苗。某些無脊髓灰質炎的國家也可能會要求來自巴基斯坦的旅客進行脊髓灰質炎免疫接種，以獲得入境簽證。由于麥加朝圣和小朝期已經開始，預計在齋月（8月）和11月初的麥加朝圣時，將會有更多的小朝，沙特阿拉伯王國已要求（所有年齡的）小朝和麥加朝圣旅客進行免疫接種。這些要求與世衛組織國際旅行和健康中所列出的建議相一致，同時該國還額外要求，來自脊灰呈地方流行國家的所有年齡旅客提供證據，證明在前往沙特阿拉伯王國六周之前曾接受口服脊髓灰質炎疫苗免疫接種，并在抵達時追加服用一劑口服脊髓灰質炎疫苗。Poliomyelitis in PakistanPakistan has reported wild poliovirus type 3 (WPV3) isolated from a 16-month old child with onset of paralysis on 9 June 2011, from a conflict-affected, inaccessible area of Khyber Agency, Federally Administered Tribal Areas (FATA). This is the only case of WPV3 detected in Asia in 2011. WPV3 transmission in Asia is on the verge of elimination, with the last case occurring more than six months ago, on 18 November 2010 (also from Khyber Agency, FATA). Confirmation of continuation of WPV3 transmission in tribal areas of Pakistan has significant implications for the global effort to eradicate WPV3, particularly as Asia is on the verge of eliminating circulation of this strain. The detection of WPV3 in Pakistan represents the risk that it may spread from this transmission focus to other WPV3-free areas of Asia and beyond. Globally, WPV3 transmission is at historically low levels in 2011, with other circulation of this strain restricted to parts of west Africa (17 cases in C?te dIvoire, Guinea, Mali and Niger), Nigeria (five cases) and Chad (three cases). The risk of onward spread of WPV3 is deemed as high by the World Health Organization (WHO), particularly given large-scale population movements within Pakistan, between Pakistan and Afghanistan, and expected large-scale population movements associated with Umrah and the upcoming Hajj (pilgrimage to Mecca, Kingdom of Saudi Arabia) in the coming few months. In 2011, supplementary immunization activities (SIAs) in Pakistan have been inadequate in quality in key high-risk areas and a significant proportion of children remained inaccessible in conflict affected tribal areas. In FATA, particularly in Khyber agency, nearly 50% of children have been regularly missed during SIAs for the last two years. In addition to challenges relating to reaching children in insecure areas of Khyber Pakhtunkhwa and FATA, significant operational challenges continue to mar the quality of SIAs in accessible areas of Khyber and in other key transmission areas of the country, notably in the provinces of Balochistan and Sindh. In addition to confirmation of the only WPV3 case in Asia in 2011, Pakistan is affected by country-wide geographical transmission of wild poliovirus type 1 (WPV1), with 57 confirmed WPV1 cases in 2011 (as at 5 July 2011), compared with 14 WPV1 cases for the same period in 2010. To urgently address the situation, the Government of Pakistan has this year launched a National Polio Emergency Action Plan, under the auspices of His Excellency the President. However, the Independent Monitoring Board (IMB), set up at the request of the World Health Assembly (WHA) in 2010 to independently monitor progress towards a polio-free world, in April 2011 expressed alarm that the Plan is taking too long to implement, a conclusion echoed by the Technical Advisory Group (TAG) of the Eastern Mediterranean in June 2011. To rapidly build up immunity to both wild poliovirus strains, a Short Interval Additional Dose Strategy (SIAD) SIA with bivalent OPV is being conducted in Khyber Agency , the first passage on 4 July and the second on 12 July. It is expected that, as during the most recent SIAs in mid-June, 45% (89,449) of target children in Khyber Agency (80% in Bara Tehsil, i.e. approximately 73,000) will remain inaccessible during the SIADs. National Immunization Days (NIDs) will be conducted in the country on 18-20 July, using bivalent OPV (containing type 1 & 3 serotypes). However, key to success will be to overcome remaining operational challenges in fully-accessible areas and to implement special outreach strategies with full community participation to increase access to populations in security-compromised areas. To minimise the risk of WPV3 re-infecting Afghanistan, Subnational Immunization Days (SNIDs) - including in border areas with Pakistan - will be conducted in the country on 10-12 July, also using bivalent OPV. It is important that countries across Asia and the Eastern Mediterranean strengthen disease surveillance for acute flaccid paralysis (AFP), in order to rapidly detect any poliovirus importations and facilitate a rapid response should importation occur. Countries should also continue to boost routine immunization coverage against all strains of polio to minimize the consequences of any introduction. As per recommendations outlined in WHOs International travel and health, travellers to and from Pakistan should be fully protected by vaccination. Travellers to Pakistan who have in the past received three or more doses of OPV should be offered another dose of polio vaccine before departure. Any unimmunized individuals intending to travel to Pakistan should complete a full course of vaccination. Travellers from Pakistan should have a full course of vaccination against polio before leaving Pakistan,